Complaint Investigation Report

336426760-1-3-2024-18-AS-RSTS-CZL33P-20240117165349

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CCLD Regional Office , 1650 SPRUCE ST STE 200 MS29-27

This is an official report of an unannounced visit/investigation of a complaint received in our office on

01/10/2022 and conducted by Evaluator Jesse Gardner

COMPLAINT CONTROL NUMBER: 18-AS-20220110092445

Staff left resident's in soiled clothing for extended periods of time

Licensing Program Analyst (LPA) Jesse Gardner conducted an unannounced subsequent complaint visit to the facility. LPA met with Administrator Marlya Dunham on the purpose of this visit. During this investigation LPA conducted interviews with staff and residents; obtained supportive documentation for review to assist with determining the findings for the above noted allegations. The following was determined.

Allegation #1 – Staff left residents in soiled clothing for extended periods of time. LPA investigation consisted of an internal record review, interviews with staff (S1, S2) and residents (R1, R2, and R3), and LPA made observations. Staff interviews revealed that R1 would display uncooperative behavior to most staff when staff went to assist R1 with changing of their diaper. One staff interview admitted that R1 was, at times, not changed for 8 hours due to staff not feeling confident in changing R1, due to R1’s behaviors. Other staff interviews revealed that R1 was difficult to change, and due to this, R1 would not be changed on their shift.

Although LPA did not observe soiled linen, smell foul odor, nor observe any resident not being cared for otherwise during the investigation, staff interviews admitted that R1 was not being changed regularly due to their behaviors. LPA could not obtain relevant information through interviews with residents due to the residents’ cognitive state. Therefore, based on the interviews conducted, this allegation was Substantiated. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

During this visit, a Type A citation was issued, per the California Code of Regulations, Title 22 Division 6, chapter 8, Article 11.

An exit interview was conducted where a copy of this report, LIC9099D, LIC811, and Appeal Rights were provided to Ms. Dunham.